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WORLD INTELLECTUAL PROPERTY ORGANIZATION
International Bureau

PCT

INTERNATIONAL APPLICATION PUBLISHED UNDER THE PATENT COOPERATION TREATY (PCT)

(51) International Patent Classification 6 :
A01N 43/04, A61K 31/70

(11) International Publication Number: WO 00/11952

(43) International Publication Date; 9 March 2000 (09.03.00)

(21) International Application Number: PCT/US99/1 9725

(22) International Filing Date; 3 1 August 1999 (31 .08.99)

(30) Priority Data:
09/144,096

31 August 1998 (31.08.98)

(63) Related by Continuation (CON) or Continuation-in-Part
(CIP) to Earlier Application

US 09/144,096 (CIP)

Filed on 31 August 1998 (31.08.98)

(71) Applicant (for all designated
PRO-NEURON, INC. [US/US];
Gaithersburg, MD 20877 (US).

States except US):
16020 Industrial Drive,

(72) Inventor; and

(75) Inventor/Applicant (for US only): VON BORSTEL, Reid, W.
fUS/US]; 8310 Fox Run, Potomac, MD 20854 (US).

(74) Agent: BYRNE, Thomas, E.; Nixon & Vanderhye P.C., Suite
800, 1100 North Glebe Road, Arlington, VA 22201-4714
(US).

(81) Designated States: AE, AL, AM, AT, AU, AZ, BA, BB, BG,
BR, BY, CA, CH, CN, CU, CZ, DE, DK, EE, ES. FI, GB,
GD, GE, GH, GM, HR, HU, ID, IL, IN, IS, JP, KE, KG,
KP, KR, KZ, LC, LK, LR, LS, LT, LU, LV, MD, MG, MK,
MN, MW, MX, NO, NZ, PL, PT, RO, RU, SD, SE, SG, SI,
SK, SL, TJ, TM, TO, TT, UA, UG, US, UZ, VN, YU, ZA,
ZW, ARIPO patent (GH, GM, KE, LS, MW, SD, SL, SZ,
UG, ZW), Eurasian patent (AM, AZ, BY, KG, KZ, MD,
RU. TJ, TM), European patent (AT, BE, CH, CY, DE, DK,
ES, FI, FR, GB, GR, IE, IT, LU, MC, NL, PT, SE), OAP1
patent (BF, BJ, CF, CG, CI, CM, GA, GN, GW, ML, MR,
NE, SN, TD, TG).

Published

With international search report

(54) Title: COMPOSITIONS AND METHODS FOR TREATMENT OF MITOCHONDRIAL DISEASES
(57) Abstract

Compounds, compositions, and methods are provided for treatment of disorders related to mitochondrial dysfunction. Hie methods
comprise administering to a mammal a composition containing pyrimidien nucleotide precursors in amounts sufficient to treat symptoms
resulting from mitochondrial respiratory chain deficiencies.

FOR THE PURPOSES OF INFORMATION ONLY

Codes used to identify States party to the PCT on the front pages of pamphlets publishing international applications under the PCT.

Albania

Spain

Lesotho

Slovenia

Armenia

Finland

Lithuania

Slovakia

Austria

France

Luxembourg

Senegal

Australia

Gabon

Latvia

Swaziland

Azerbaijan

United Kingdom

Monaco

Chad

Bosnia and Herzegovina

Georgia

Republic of Moldova

Togo

Barbados

Ghana

Madagascar

Tajikistan

Belgium

Guinea

The former Yugoslav

Turkmenistan

Burkina Faso

0 recce

Republic of Macedonia

Turkey

Bulgaria

Hungary

Mali

Trinidad and Tobago

Benin

Ireland

Mongolia

Ukraine

Brazil

Israel

Mauritania

Uganda

Belarus

Iceland

Malawi

United States of America

Canada

Italy

Mexico

Uzbekistan

Central African Republic

Japan

Niger

Viet Nam

Congo

Kenya

Netherlands

Yugoslavia

Switzerland

Kyrgyzstan

Norway

Zimbabwe

Cflte d'lvoire

Democratic People's

New Zealand

Cameroon

Republic of Korea

Poland

China

Republic of Korea

Portugal

Cuba

Kazakstan

Romania

Czech Republic

Saint Lucia

. w

Russian Federation

Germany

Liechtenstein

Sudan

Denmark

Sri Lanka

Sweden

Estonia

Liberia

Singapore

WO 00/11952 PCT/US99/19725

COMPOSITIONS AND METHODS FOR TREATMENT
OF MITOCHONDRIAL DISEASES

Field of the Invention

This invention relates generally to compounds and methods for treatment and prevention
of diseases, developmental delays, and symptoms related to mitochondrial dysfunction.
Pyrimidine nucleotide precursors are administered to a mammal, including a human, for the
purpose of compensating for mitochondrial dysfunction and for improving mitochondrial
functions.

Background of the Invention

Mitochondria are cellular organelles present in most eukaryotic cells. One of their
primary functions is oxidative phosphorylation, a process through which energy derived from
metabolism of fuels like glucose or fatty acids is converted to ATP, which is then used to drive
various energy-requiring biosynthetic reactions and other metabolic activities. Mitochondria
have their own genomes, separate from nuclear DNA, comprising rings of DNA with about
1 6,000 base pairs in human cells. Each mitochondrion may have multiple copies of its genome,
and individual cells may have hundreds of mitochondria.

Mitochondrial dysfunction contributes to various disease states. Some mitochondrial
diseases are due to mutations or deletions in the mitochondrial genome. Mitochondria divide
and proliferate with a faster turnover rate than their host cells, and their replication is under
control of the nuclear genome. If a threshold proportion of mitochondria in a cell is defective,
and if a threshold proportion of such cells within a tissue have defective mitochondria,
symptoms of tissue or organ dysfunction can result. Practically any tissue can be affected, and
a large variety of symptoms may be present, depending on the extent to which different tissues
are involved.

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A fertilized ovum might contain both normal and genetically defective mitochondria.
The segregation of defective mitochondria into different tissues during division of this ovum is
a stochastic process, as will be the ratio of defective to normal mitochondria within a given
tissue or cell (although there can be positive or negative selection for defective mitochondrial
genomes during mitochondrial turnover within cells). Thus, a variety of different pathologic
phenotypes can emerge out of a particular point mutation in mitochondrial DNA. Conversely,
similar phenotypes can emerge from mutations or deletions affecting different genes within
mitochondrial DNA. Clinical symptoms in congenital mitochondrial diseases often manifest in
postmitotic tissues with high energy demands like brain, muscle, optic nerve, and myocardium,
but other tissues including endocrine glands, liver, gastrointestinal tract, kidney, and
hematopoietic tissue are also involved, again depending in part on the segregation of
mitochondria during development, and on the dynamics of mitochondrial turnover over time.

In addition to congenital disorders involving inherited defective mitochondria, acquired
mitochondrial dysfunction contributes to diseases, particularly neurodegenerative disorders
associated with aging like Parkinson's, Alzheimer's, Huntington's Diseases. The incidence of
somatic mutations in mitochondrial DNA rises exponentially with age; diminished respiratory
chain activity is found universally in aging people. Mitochondrial dysfunction is also
implicated in excitotoxic neuronal injury, such as that associated with seizures or ischemia.

Treatment of diseases involving mitochondrial dysfunction has heretofore involved
administration of vitamins and cofactors used by particular elements of the mitochondrial
respiratory chain. Coenzyme Q (ubiquinone), nicotinamide, riboflavin, carnitine, biotin, and
lipoic acid are used in patients with mitochondrial disease, with occasional benefit, especially in
disorders directly stemming from primary deficiencies of one of these cofactors. However,
while useful in isolated cases, no such metabolic cofactors or vitamins have been shown to have
general utility in clinical practice in treating mitochondrial diseases. Similarly, dichloracetic
acid (DC A) has been used to treat mitochondrial cytopathies such as MEL AS; DC A inhibits
lactate formation and is primarily useful in cases of mitochondrial diseases where excessive
lactate accumulation itself is contributing to symptoms. However, DCA does not address
symptoms related to mitochondrial insufficiency per se and can be toxic to some patients,
depending on the underlying molecular defects.

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Mitochondrial diseases comprise disorders caused by a huge variety of molecular lesions
or defects, with the phenotypic expression of disease further complicated by stochastic
distributions of defective mitochondria in different tissues.

Commonly owned United States Patent 5,583,1 17 discloses acylated derivatives of
cytidine and uridine. Commonly owned application PCT/US 96/10067 discloses the use of
acylated pyrimidine nucleosides to reduce the toxicity of chemotherapeutic and antiviral
pyrimidine nucleoside analogs.

Objects of the Invention

It is an object of the invention to provide compositions and methods for treating
disorders or pathophysiological consequences associated with mitochondrial dysfunction or
mitochondrial respiratory chain dysfunction in a mammal, including a human.

It is an object of the invention to provide compounds and compositions that improve
tissue resistance to mitochondrial dysfunction in vivo.

It is an object of the invention to provide compositions and methods for treatment of
mitochondrial diseases.

It is an object of the invention to provide agents which compensate broadly for
mitochondrial deficits involving a wide variety of molecular pathologies, since, in many cases,
precise diagnosis of molecular lesions in mitochondrial disorders is difficult.

It is an object of the invention to provide a practical treatment for mitochondrial diseases
that is beneficial in the case of mitochondrial electron transport chain deficits regardless of the
specific molecular defects.

It is an object of the invention to provide not only for the relatively rare congenital
diseases related to mitochondrial DNA defects, but also for significant neuromuscular and

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neurodevelopmental disorders that appear in childhood and for common age-related
degenerative diseases like Alzheimer's or Parkinsons Diseases.

It is an object of the invention to provide compositions and methods for treatment and
prevention of neurodegenerative and neuromuscular disorders.

It is an object of the invention to provide compositions and methods for treatment and
prevention of excitotoxic injury to neural tissue.

It is an object of the invention to provide compositions and methods for treatment and
prevention of epilepsy.

It is an object of the invention to provide compositions and methods for treatment and
prevention of migraine.

It is an object of the invention to provide compositions and methods for preventing
death or dysfunction of postmitotic cells in a mammal, including a human.

It is an object of the invention to provide compositions and methods for treatment of
neurodevelopmental delay disorders

It is a further object of the invention to provide a composition for treatment or
prevention of tissue damage due to hypoxia or ischemia .

It is a further object of this invention to provide compositions and methods for treating
or preventing ovarian dysfunction, menopause, or secondary consequences of menopause.

It is a further object of the invention to provide compositions and methods for reducing
side effects of cancer chemotherapies due to chemotherapy-induced mitochondrial injury.

It is a further object of the invention to provide a method for diagnosing mitochondrial
disease and dysfunction.

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Summary of the Invention

The subject invention provides a method for treating pathophysiological consequences
of mitochondrial respiratory chain deficiency in a mammal comprising administering to such a
mammal in need of such treatment an amount of a pyrimidine nucleotide precursor effective in
reducing the pathophysiological consequences. Additionally, the invention provides a method
of preventing pathophysiological consequences of mitochondrial respiratory chain deficiency
comprising administering to a mammal an amount of a pyrimidine nucleotide precursor
effective in preventing the pathophysiological consequences.

In mitochondrial disease the compounds and compositions of the invention are useful
for attenuating clinical sequelae stemming from respiratory chain deficiencies. Respiratory
chain deficiencies underlying mitochondrial disease are caused by various factors including
congenital or inherited mutations anddeletions in mitochondrial DNA, deficits in nuclear-
encoded proteins affecting respiratory chain activity, as well as somatic mutations, elevated
intracellular calcium, excitotoxicity, nitric oxide, hypoxia and axonal transport defects.

The subject invention provides compounds, compositions, and methods for preventing
or reducing death and dysfunction of postmitotic cells bearing mitochondrial respiratory chain
deficits.

The subject invention furthermore provides compounds, compositions, and methods for
treating neurodevelopmental delays in language, motor, executive function, cognitive, and
neuropsychological social skills.

The subject invention also relates to treatment of disorders and conditions that are herein
disclosed as conditions to which mitochondrial defects contribute and which therefore are
subject to treatment with compounds, and compositions of the invention. These include side
effects of cancer chemotherapy like peripheral neuropathies, nephropathies, fatigue, and early
menopause, as well as ovulatory abnormalities and normal menopause itself.

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The subject invention also relates to a method for diagnosing mitochondrial diseases by
treating patients with a pyrimidine nucleotide precursor and assessing clinical benefit in -
selected signs and symptoms.

The invention, as well as other objects, features and advantages thereof will be
understood more clearly and fully from the following detailed description, when read with
reference to the accompanying results of the experiments discussed in the examples below.

Detailed Description of the Invention

The subject invention is related to compounds, compositions, and methods for treating
or preventing a variety of clinical disorders secondary to mitochondrial dysfunction, especially
deficits in the activity of components of the mitochondrial respiratory chain. Such disorders
include congenital mitochondrial cytopathies, neurodevelopmental delays, age-related
neurodegenerative diseases, as well as particular diseases affecting the heart, peripheral and
autonomic nerves, skeletal muscle, pancreas and other tissues and organs.

A. Definitions

"Mitochondrial disease" refers to disorders to which deficits in mitochondrial respiratory
chain activity contribute in the development of pathophysiology of such disorders in a mammal.
This category includes 1) congenital genetic deficiencies in activity of one or more components
of the mitochondrial respiratory chain; 2) acquired deficiencies in the activity of one or more
components of the mitochondrial respiratory chain, wherein such deficiencies are caused by,
inter alia, a) oxidative damage during aging; b) elevated intracellular calcium; c) exposure of
affected cells to nitric oxide; d)hypoxia or ischemia; e) microtubule-associated deficits in
axonal transport of mitochondria, or f) expression of mitochondrial uncoupling proteins.

The mitochondrial respiratory chain (also known as the electron transport chain)
comprises 5 major complexes:

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Complex I NADH:ubiquinone reductase

Complex II Succinate:ubiquinone reductase

Complex III ubiquinol:cytochrome-c reductase

Complex IV cytochrome-c oxidase

Complex V ATP synthase

Complexes I and II accomplish the transfer of electrons from metabolic fuels like
glycolysis products and fatty acids to ubiquinone (Coenzyme Q), converting it to ubiquinol.
Ubiquinol is converted back to ubiquinone by transfer of electrons to cytochrome c in Complex
ffl. Cytochrome c is reoxidized at Complex IV by transfer of electrons to molecular oxygen, -
producing water. Complex V utilizes potential energy from the proton gradient produced across
the mitochondrial membrane by these electron transfers, converting ADP into ATP, which then
provides energy to metabolic reactions in the cell.

Dihydro-orotate dehydrogenase (DHODH), is an enzyme involved in de novo synthesis
of uridine nucleotides. DHODH activity is coupled to the respiratory chain via transfer of
electrons from dihydro-orotate to ubiquinone; these electrons are then passed onto cytochrome c
and oxygen via Complexes ffl and IV respectively. Only Complexes III and IV are directly
involved in pyrimidine biosynthesis. Orotate produced by the action of DHODH is converted to
uridine monophosphate by phosphoribosylation and decarboxylation.

"Pyrimidine nucleotide precursors" in the context of the invention are intermediates in
either the de novo or salvage pathways of pyrimidine nucleotide synthesis that enter into -
pyrimidine synthesis either distal to DHODH (e.g. orotate) or which do not require DHODH
activity for conversion to pyrimidine nucleotides (e.g. cytidine, uridine, or acyl derivatives of-
ytidine or uridine). Also included within the scope of the invention are pyrimidine nucleoside
phosphates (eg. nucleotides, cytidine diphosphocholine, uridine diphosphoglucose); these
compounds are degraded to the level of uridine or cytidine prior to entry into cells and
anabolism. Acyl derivatives of cytidineand uridine have better oral bioavailability than the
parent nucleosides or nucleotides. Orotic acid and esters thereof are converted to uridine
nucleotides and are also useful for accomplishing the goals of the invention.

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R Compound s "f the Invention

A primary feature of the present invention is the unexpected discovery that
administration of pyrimidine nucleotide precursors is effective in treatment of a large variety of
symptoms and disease states related to mitochondrial dysfunction.

Tissue pyrimidine nucleotide levels are increased by adininistration of any of several
precursors. Uridine and cytidine are incorporated into cellular nucleotide pools by
phosphorylation at the 5' position; cytidine and uridine nucleotides are interconvertible through
enzymatic amination and de-amination reactions. Orotic acid is a key intermediate in de novo
biosynthesis of pyrimidine nucleotides. Incorporation of orotic acid into nucleotide pools
requires cellular phosphoribosyl pyrophosphate (PRPP). Alternatively (or in addition to
provision of exogenous nucleotide precursors),availability of uridine to tissues is increased by
administration of compounds which inhibit uridine phosphorylase, the first enzyme in the
pathway for degradation of uridine. The compounds of the invention useful in treating
mitochondrial diseases andrelated disorders include uridine, cytidine, orotate, orally
bioavailable acyl derivatives or esters of these pyrimidine nucleotide precursors, and inhibitors
of the enzyme uridine phosphorylase.

In reference to acyl derivatives of cytidine and uridine, the following definitions pertain:

The term "acyl derivative" as used herein means a derivative of a pyrimidine nucleoside
in which a substantially nontoxic organic acyl sub-stituent derived from a carboxylic acid is
attached to one or more of the free hydroxyl groups of the ribose moiety of the oxy-purine
nucleoside with an ester linkage and/orwhere such a substituent is attached to the amine
substituent on the purine ring of cytidine, with an amide linkage. Such acylsubstituents are
derived from carboxylic acids which include, but are not limited to, compounds selected from
the group consisting of a fatty acid, an amino acid, nicotinic acid, di-carboxylic acids, lactic
acid, p-aminobenzoic acid and orotic acid. Advantageous acyl substituents are compounds
which are normally present in the body, either as dietary constituents or as intermediary
metabolites.

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The term "pharmaceutically acceptable salts" as used herein means salts with
pharmaceutical* acceptable acid or base addition salts of the derivatives, which include, but are
not limited to, sulfuric, hydrochloric, or phosphoric acids, or, in the case of orotate, sodium or
calcium hydroxides, and canonic amino acids, especially lysine.

The term "amino acids" as used herein includes, but is not limited to, glycine, the L
forms of alanine, valine, leucine, isoleucine, phenyl-alanine, tyrosine, proline, hydroxyproline, -
serine, threonine, cysteine, cystine, methionine, tryptophan,aspartic acid, glutamic acid,
arginine, lysine, histidme.omithine, hydroxyzine, carnitine, and other naturally occurring
amino acids.

The term "fatty acids" as.used herein means aliphatic carboxylic acids having 2-22
carbon atoms. Such fatty acids maybe saturated, partially saturated or polyunsaturated.

The term "dicarboxylic acids" as used herein means fatty acids with a second carboxylic
acid substituent.

Compounds of the invention have the following structures:

In all cases except where indicated, letters and letters with subscripts symbolizing
variable substituents in the chemical structures of the compounds of the invention are applicable
only to the structure immediately preceding the description of the symbol.

(1) An acyl derivative of uridine having the formula:

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wherein Rl, R2, R3 and R4 are the same or different and each is hydrogen or an acyl
a metabolite, provided that at least one of said R substituents is not hydrogen, or a
pharmaceutically acceptable salt thereof.

(2) An acyl derivative of cytidine having the formula:

NHR 4

R 2 0 OR 3

wherein Rl, R2, R3 and R4 are the same or different and each is hydrogen or an acyl radical of
a metabolite, provided that at least one of said R substituents is not hydrogen, or a -
pharmaceutically acceptable salt thereof.

The compounds of the invention useful in treating mitochondrial diseases include:
(3) An acyl derivative of uridine having the formula:

R 2 0 OR 3

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wherein Rl, R2, and R3 are the same, or different, and each is hydrogen or an acyl radical of

a. an unbranched fatty acid with 2 to 22 carbon atoms,

b. an amino acid selected from the group consisting ofglycine, the L forms of
alanine, valine, leucine, isoleucine, tyrosine, proline, hydroxyproline, serine, threonine, cystine,
cysteine, aspartic acid, glutamic acid, arginine, lysine, histidine, carnitine and ornithine,

c. a dicaiboxylic acid having 3-22 carbon atoms,

d. a carboxylic acid selected from one or more of the group consisting of glycolic
acid, pyruvic acid, lactic acid, enoipyruvic acid, lipoic acid, pantothenic acid, acetoacetic acid,
p-aminobenzoic acid, betahydroxybutyric acid, orotic acid, and creatine.

(4) An acyl derivatives of cytidine having the formula:

NHR 4

R 2 0. OR 3

wherein Rl, R2, R3, and R4 are the same, or different, and each is hydrogen or an acyl radical
of

a. an unbranched fatty acid with 2 to 22 carbon atoms,

b. an amino acid selected from the group consisting of glycine, the L forms of
phenylalanine, alanine, valine, leucine, isoleucine, tyrosine, proline, hydroxyproline, serine,
threonine, cystine, cysteine, aspartic acid, glutamic acid, arginine, lysine, histidine carnitine and
ornithine,

c. a dicarboxylic acid having 3-22 carbon atoms,

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d. a carboxylic acid selected from one or more of the group consisting of glycolic
acid, pynivic acid, lactic acid, enolpymvic acid, lipoic acid, pantothenic acid, acetoacetic acid,
p-aminobenzoic acid, betahydroxybutyric acid, orotic acid, and creatine.

(5) An acyl derivative of uridine having the formula:

wherein at least one of Rl, R2, or R3 is a hydrocarbyloxycarbonyl moiety containing 2-26
carbon atoms and the remaining R substituents are independently a hydrocarbyloxycarbonyl
hydrocarbylcarbonyi moiety or H or phosphate,

(6) An acyl derivative of cytidine having the formula:

NHR<

R 2 0 OR3

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wherein at least one of Rl, R2, R3 or R4 is a hydrocarbyloxycarbonyl moiety containing 2-:
carbon atoms and the remaining R substituents are independently ahydrocarbyloxycarbonyl
hydrocarbylcarbonyl moiety or H or phosphate.

(7) Orotic acid or salts thereof:

COOH

Pharmaceutically-acceptable salts of orotic acid include those in which the cationic
component of the salt is sodium, potassium, a basic amino acid such as arginine or lysine,
methylglucamine, choline, or any other substantially nontoxic water soluble cation with a
molecular weight less than about 1 000 daltons.

8) Alcohol-substituted orotate derivatives:

COOR,

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wherein Rl is a radical of an alcohol containing I to 20 carbon atoms joined to orotate via an
ester linkage.

Also encompassed by the invention are the pharmaceutically acceptable salts of the
above-noted compounds.

Advantageous compounds of the invention are short-chain (2 to 6 carbon atoms) fatty
acid esters of uridine or cytidine. Particularly advantageous compounds are triacetyluridine or
triacetylcytidine. Such compounds have better oral bioavailabilty than the parent nucleosides,
and are rapidly deacetylated following absorption after oral administration.

Pyruvic acid is useful for treatment of cells with defective mitochondrial function. Cells
with reduced capability for mitochondrial oxidative phosphorylation must rely on glycolysis for
generation of ATP. Glycolysis is regulated by the redox state of cells. Specifically, NAD+ is
required for optimal glucose flux, producing NADH in the process. In order to maximize
energy production from glycolysis, NADH must be reoxidized to NAD+. Exogenous pyruvate
can reoxidize NADH, in part via a plasma membrane enzyme, NADH Oxidase,

Uridine tripyruvate (2\3\5 , -tri-0-pyruvyluridine) provides the benefits of both
pyrimidines and pyruvate, delivering both with a single chemical entity, and avoiding the load
of sodium, calcium, or other cations in the corresponding salts of pyruvic acid.

Inhibitors of uridine phosphorvlase

An alternative or complementary strategy for treating mitochondrial diseases involves
inhibition of uridine catabolism with an inhibitor of the enzyme uridine phosphorylase.

Examples of inhibitors of uridine phosphorylase that are useful for treatment of
mitochondrial disease include but are not limited to 5-benzyl barbiturate or 5-benzylidene
barbiturate derivatives including 5-benzyl barbiturate, 5-benzyloxybenzylbarbiturate, 5-
benzyloxybenzyl--l-[(l-hydroxy-2«ethoxy)methyl]barbiturate, 5-benzyloxybenzylacetyl-l-
[(l-hydroxy-2-ethoxy)methyl] barbiturate, and 5-methoxybenzylacetyl-acyclobarbiturate, 2,2'-

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anhydro-5-ethyluridine,5-ethyl-2-deoxyuridine and acyclouridine compounds, particularly5-
benzyl substituted acyclouridine congeners including but notlimited to benzylacyclouridine,
benzyloxy-benzyl-acyclo-uri(iine,ammomethyI--benzyl-a(7clouridine,
aminomethyl--benzyloxy-ber^lacyclouridine,h^

hydroxyinethyl-benzyloxy-benzyl-acyclouridine. See also WO 89/09603and WO 91/16315,
hereby incorporated by reference.

C. Compositions of the Invention

In one embodiment of the invention, novel pharmaceutical compositions comprise as an
active agent one or more pyrimidine nucleotide precursors selected from the group consisting
of uridine, cytidine, orotic acid or its salts or esters, and acyl derivatives of these pyrimidine
nucleotide precursors, together with a pharmaceutically acceptable carrier.

The compositions, depending on the intended use and route of administration, are
manufactured in the form of a liquid, a suspension, sprinkles, microcapsules, a tablet, a capsule,
a dragee, an injectable solution, or a suppository (see discussion of formulation below).

In another embodiment of the invention, the composition comprises at least one
pyrimidine nucleotide precursor and an agent which inhibits the degradation of uridine, such as
an inhibitor of the enzyme uridine phosphorylase. Examples of inhibitors of uridine
phosphorylase include but are not limited to 5-benzyl barbiturate or 5-benzylidene barbiturate
derivatives including 5-benzyl barbiturate, 5-benzyloxybenzyl barbiturate, 5-benzyloxybenzyl-
H(l-hydroxy-2-etooxy)methyl] barbie
ethoxy)methyl]barbiturate, and 5-me^^

ethyluridine, and acyclouridine compounds, particularly 5-benzyl substituted acyclouridine
congeners including but not limited to benzylacyclouridine, benzyloxy-benzyl-acyclo-uridine,
arninomemyl--benzyl-acyclouridine,aminom

hydroxymethyl--ber^lacyclouridine,andhydroxymethyl-beiizyloxy-benzyl-acyclouridm^
Furthermore, it is within the scope of the invention to utilize an inhibitor of uridine
phosphorylase alone, without coadministration of a pyrimidine nucleotide precursor, for the

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purpose of treating mitochondrial diseases or pathophysiologies associated with mitochondrial
respiratory chain dysfunction.

Further embodiments of the invention comprise a pyrimidine nucleotide precursor
combined with one or more other agents with protective or supportive activity relative to
mitochondrial structure and function. Such agents, presented with recommended daily doses in
mitochondrial diseases include, but are not limited to, pyruvate (1 to 10 grams/day), Coenzyme
Q (1 to 4mg/kg/day), alanine (1-10 grams/day), lipoic acid (1 to lOmg/kg/day), carnitine (10 to
100 mg/kg/day), riboflavin (20 tolOO mg/day, biotin (1 to 10 mg/day), nicotinamide (20 to 100-
mg/day), niacin (20 to 100 mg/day), Vitamin C (100 to lOOOmg/day), Vitamin E (200-400
mg/day), and dichloroacetic acid or its salts. In the case of pyruvate, this active agent can be
administered as pyruvic acid, pharmaceutically acceptable salts thereof, or pyruvic acid esters
having an alcohol moiety containing 2 to 10 carbon atoms.

P. Therapeutic Uses of the Compoun d s and Compositions of the Invention

Diseases related to mitochondrial respiratory chain dysfunction can be divided into
several categories based on the origin of mitochondrial defects.

Congenital mitochondrial diseases are those related to hereditary mutations, deletions, or
other defects in mitochondrial DNA or in nuclear genes regulating mitochondrial DNA
integrity, or in nuclear genes encoding proteins that are critical for mitochondrial respiratory
chain function.

Acquired mitochondrial defects comprise primarily 1) damage to mitochondrial DNA
due to oxidative processes or aging; 2)mitochondrial dysfunction due to excessive intracellular
and intramitochondrial calcium accumulation; 3) inhibition of respiratory chain complexes with
endogenous or exogenous respiratory chain inhibitors; 4) acute or chronic oxygen deficiency;
and 5) impaired nuclear-mitochondrial interactions, e.g. impaired shuttling of mitochondria in
long axons due to microtubule defects, and 6) expression of mitochondrial uncoupling proteins
in response to lipids, oxidative damage or inflammation.

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The most fundamental mechanisms involved in acquired mitochondrial defects, and
which underlie pathogenesis of a variety of forms of organ and tissue dysfunction, include:

Calcium accumulation: A fundamental mechanism of cell injury, especially in excitable
tissues, involves excessive calcium entry into cells, as a result of either leakage through the
plasma membrane or defects in intracellular calcium handling mechanisms. Mitochondria are
major sites of calcium sequestration, and preferentially utilize energy from the respiratory chain
for taking up calcium rather than for ATP synthesis, which results in a downward spiral of
mitochondrial failure, since calcium uptake into mitochondria results in diminished capabilities
for energy transduction.

Excitotoxicity: Excessive stimulation of neurons with excitatory amino acids is a common
mechanism of cell death or injury in the central nervous system. Activation of glutamate
receptors, especially of the subtype designated NMDA receptors, results in mitochondrial
dysfunction, in part through elevation of intracellular calcium during excitotoxic stimulation. -
Conversely, deficits in mitochondrial respiration and oxidative phosphorylation sensitizes cells
to excitotoxic stimuli, resulting in cell death or injury during exposure to levels of excitotoxic
neurotransmitters or toxins that would be innocuous to normal cells.

Nitric oxide exposure: Nitric oxide (~1 micromolar) inhibits cytochrome oxidase (Complex
IV) and thereby inhibits mitochondrial respiration (Brown GC, Mol. Cell. Biochem.l74:189-
192, 1997); moreover, prolonged exposure to NO irreversibly reduces Complex I activity.
Physiological or pathophysiological concentrations of NO thereby inhibit pyrimidine
biosynthesis. Nitric oxide is implicated in a variety of neurodegenerative disorders including
inflammatory and autoimmune diseases of the central nervous system, and is involved in
mediation of excitotoxic and post-hypoxic damage to neurons.

Hypoxia: Oxygen is the terminal electron acceptor in the respiratory chain. Oxygen deficiency
impairs electron transport chain activity, resulting in diminished pyrimidine synthesis as well as
diminished ATP synthesis via oxidative phosphorylation. Human cells proliferate and retain
viability under virtually anaerobic conditions if provided with uridine and pyruvate (or a -
similarly effective agent for oxidizing NADH to optimize glycolytic ATP production).

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Nuclear-mitochondrial interactions: Transcription of mitochondrial DNA encoding
respiratory chain components requires nuclear factors. In neuronal axons, mitochondria must
shuttle back and forth to the nucleus in order to maintain respiratory chain activity. If axonal
transport is impaired by hypoxia or by drugs like taxol which affect microtubule stability,
mitochondria distant from the nucleus undergo loss of cytochrome oxidase activity.

Mitochondrial Uncoupling Proteins: Mitochondria are the primary source of free radicals and
reactive oxygen species, due to spillover from the mitochondrial respiratory chain, especially
when defects in one or more respiratory chain components impairs orderly transfer of electrons
from metabolic intermediates to molecular oxygen. To reduce oxidative damage, cells can
compensate by expressing mitochondrial uncoupling proteins (UCP), of which several have
been identified. UCP-2 is transcribed in response to oxidative damage, inflammatory cytokines,
or excess lipid loads, e.g. fatty liver and steatohepatitis. UCP reduce spillover of reactive
oxygen species from mitochondria by discharging proton gradients across the mitochondrial
inner membrane, in effect wasting energy produced by metabolism and rendering cells
vulnerable to energy stress as a trade-off for reduced oxidative injury.

In the nervous system especially, mitochondrial respiratory chain deficits have two
generalizable consequences: 1) Delayed or aberrant development of neuronal circuits within the
nervous system; and 2) accelerated degeneration of neurons and neural circuits, either acutely or
over a period of years, depending on the severity of the mitochondrial deficits and other-
precipitating factors. Analogous patterns of impaired development and accelerated
degeneration pertain to non-neural tissues and systems as well.

Mitochondrial dysfunction and pyrimidim biosynthesis

Cells with severely damaged mitochondria (including total deletion of mitochondrial
DNA, with a consequent shutdown of respiratory chain activity) can survive in culture if
provided with two agents which compensate for critical mitochondrial functions: uridine and
pyruvate. Uridine is required in vitro because a limiting enzyme for de novo synthesis of
uridine nucleotides, dihydro-orotate dehydrogenase (DHODH), is coupled to the mitochondrial

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respiratory chain, via ubiquinone as a proximal electron acceptor, cytochrome c as an
intermediate, and oxygen as a terminal electron acceptor (Loffler et al., Mol. Cell. Biochem.-
174:125-129, 1997). DHODH is required for synthesis of orotate, which is then
phosphoribosylated and decarboxylated to produce uridine monophosphate (UMP). All other
pyrimidines in cells are derived from UMP. Cells from patients with mitochondrial disease due
to defects in mitochondrial DNA require exogenous uridine in order to survive outside of the
milieu of the body, wherein pyrimidines, derived from other cells or the diet, and transported
via the circulation, are prima facie sufficient to support their viability (Bourgeron, et al.
Neuromusc. Disord. 3:605-608, 1993). Significantly, intentional inhibition of DHODH with
drugs like Brequinar or Leflunomide results in dose-limiting cytotoxic damage to the
hematopoietic system and gastrointestinal mucosa, in contrast to the predominant involvement
of postmitotic tissues like the nervous system and muscle in clinical mitochondrial disease.

Pathophysiological consequences of respiratory chain dysfunction

Mitochondria are critical for the survival and proper function of almost all types of
eukaryotic cells. Mitochondria in virtually any cell type can have congenital or acquired defects
that affect their function. Thus, the clinically significant signs and symptoms of mitochondrial
defects affecting respiratory chain function are heterogeneous and variable depending on the
distribution of defective mitochondria among cells and the severity of their deficits, and upon
physiological demands upon the affected cells. Nondividing tissues with high energy
requirements, e.g. nervous tissue, skeletal muscle and cardiac muscle are particularly
susceptible to mitochondrial respiratory chain dysfunction, but any organ system can be
affected.

The diseases and symptoms listed below comprise known pathophysiological
consequences of mitochondrial respiratory chain dysfunction and as such are disorders in which
the compounds and compositions of the invention have therapeutic utility.

Disease symptoms secondary to mitochondrial dysfunction are generally attributed to 1)
spillover of free radicals from the respiratory chain; 2) deficits in ATP synthesis leading to
cellular energy failure, or 3) apoptosis triggered by release of mitochondrial signals like

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cytochrome c which initiate or mediate apoptosis cascades. An unexpected feature of the instant
invention is the observation that pyrimidine nucleotide precursors of the invention have
therapeutic activity against a large variety of symptoms in patients with mitochondrial disease,
as shown in the Examples. This constitutes an important paradigm shift in the understanding of
pathogenesis of diseases involving mitochondrial dysfunction, and in understanding how to
treat such disorders.

Treatment of coneenital mitochondrial cvtonathies
Mitochondrial DNA defects

A number of clinical syndromes have been linked to mutations or deletions in
mitochondrial DNA. Mitochondrial DNA is inherited maternally, with virtually all of the
mitochondria in the body derived from those provided by the oocyte. If there is a mixture of
defective and normal mitochondria in an oocyte, the distribution and segregation of
mitochondria is a stochastic process. Thus, mitochondrial diseases are often multisystem
disorders, and a particular point mutation in mitochondrial DNA, for example, can result in
dissimilar sets of signs and symptoms in different patients. Conversely, mutations in two
different genes in mitochondrial DNA can result in similar symptom complexes.

Nonetheless, some consistent symptom patterns have emerged in conjunction with
identified mitochondrial DNA defects, and these comprise the classic "mitochondrial diseases",
some of which are listed immediately below. Nonetheless, an important aspect of the subject
invention is the recognition that the concept of mitochondrial disease and its treatment with
compounds and compositions of the invention extends to many other disease conditions which
are also disclosed herein.

Some of the classical phenotypes of major mitochondrial diseases associated with
mutations or deletions of mitochondrial DNA include:

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MELAS: (Mitochondrial Encephalomyopathy Lactic Acidemia, and Stroke-like episodes.

MERRF: Myoclonic Epilepsy with "Ragged Red" (muscle) Fibers

MNGIE: Mitochondrial neurogastrointestinal encephalomyopathy
NARP: Neurogenic muscle weakness, Ataxia and Retinitis Pigmentosa

LHON: Leber's Hereditary Optic Neuropathy

Leigh's Syndrome (Subacute Necrotizing Encephalomyopathy)

PEO: Progressive External Opthalmoplegia

Kearns-Sayres Syndrome (PEO, pigmentary retinopathy, ataxia, and heart-block)

Other common symptoms of mitochondrial diseases which may be present alone or in
conjunction with these syndromes include cardiomyopathy, muscle weakness and atrophy,
developmental delays(involving motor, language, cognitive or executive function),ataxia,
epilepsy, renal tubular acidosis, peripheral neuropathy.optic neuropathy, autonomic neuropathy,
neurogenic bowel dysfunction, sensorineural deafness, neurogenic bladder dysfunction, dilating
cardiomyopathy, migraine, hepatic failure, lactic acidemia, and diabetes mellitus.

In addition, gene products and tRNA encoded by mitochondrial DNA, many proteins
involved in, or affecting, mitochondrial respiration and oxidative phosphorylation are encoded
by nuclear DNA. In fact, approximately 3000 proteins, or 20% of all proteins encoded by the
nuclear genome, are physically incorporated into, or associated with, mitochondria and
mitochondrial functions or biogenesis, although only about 100 are directly involved as
structural components of the respiratory chain. Therefore, mitochondrial diseases involve not
only gene products of mitochondrial DNA, but also nuclear encoded proteins affecting
respiratory chain function and mitochondrial structure.

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Metabolic stressors like infections can unmask mitochondrial defects that do not
necessarily yield symptoms under normal conditions. Neuromuscular or neurological setbacks
during infection are a hallmark of mitochondrial disease. Conversely, mitochondrial respiratory
chain dysfunction can render cells vulnerable to stressors that would otherwise be innocuous.

Diagnosis of congenital mitochondrial disease is challenging, due to the heterogeneity of
symptoms, even between patients affected with the same molecular defect. Deficits in cell and
tissue function due to mitochondrial dysfunction can mimic tissue dysfunction caused by
problems that do not directly involve mitochondrial defects. Several clinically useful and
practical schemes for diagnosis of mitochondrial diseases are known in the art; they typically
involve several major criteria (e.g. classical clinical phenotypes like MELAS, NARP or Leigh's
Syndrome, extreme (>80%) depressions of respiratory chain complex activity in fresh tissue
samples) with a good degree of certainty in establishing the role of respiratory chain
dysfunction in disease pathogenesis, and a larger number of minor criteria (e.g. moderate
biochemical abnormalities characteristic of respiratory chain defects, symptoms characteristic
of mitochondrial diseases without full presentation of one of the classical phenotypes listed
above) which individually are less compelling than single major criteria, but which
cumulatively provide strong evidence for the contribution of respiratory chain deficits to a
particular patient's clinical presentation, as described in Walker et al. (Eur Neurol, 36:260-7,
1 996), hereby incorporated by reference.

As is demonstrated in the Examples, compounds and compositions of the invention are
useful for treatment of a very broad spectrum of signs and symptoms in mitochondrial diseases
with different underlying molecular pathologies. Improvements observed in these and
additional patients include but are not limited to reduction of frequency and severity of seizures,
migraines, and stroke-like episodes, improvement of weight gain in children with "failure to
thrive", amelioration of renal tubular acidosis with concurrent reduction in the need for
supplementary bicarbonate, improvement of muscular strength, improvement of speech
acquisition, improvement of ataxia, reduction of the frequency and severity of sinus and ear
infections, improvement of memory, and amelioration of symptoms of autonomic and
peripheral neuropathy. The improvements observed in a broad variety of symptoms which were
basically nonresponsive to other forms of metabolic support, e.g. vitamins and cofactors known

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to be necessary for proper mitochondrial function (which argues against attribution of benefits
to a placebo effect, as does recurrence of symptoms when pyrimidine support is withdrawn)
demonstrate a major unexpected insight of the invention, that functional or conditional
pyrimidine deficiency underlies a wide variety of dominant symptoms in patients with
mitochondrial diseases and that pyrimidine supplementation is sufficent to improve or
ameliorate a broad variety of symptoms in such patients. Hitherto, symptoms of mitochondrial
disease have been attributed to ATP deficiency, reactive oxygen species generated by the
defective respiratory chain, or to cell death triggered by mitochondrial components of the
apoptosis cascade. The dose limiting toxicity of inhibitors of de novo pyrimidine synthesis are
typically due to inhibition of proliferation of rapidly dividing cell types like bone marrow and
gut mucosal stem cells. Unexpectedly, therapeutic benefits of compounds and methods of the
invention in patients and experimental animals have been demonstrated in tissues comprising
nondividing postmitotic cells, e.g. central and peripheral neurons and skeletal and cardiac
muscle.

An important feature of the subject invention is the unexpected result that treatment of
patients with mitochondrial disease caused by a variety of underlying molecular defects results
in clinical improvement in a diverse assortment of symptoms in vivo in patients (Examples 1-4).
It is significant and further unexpected that clinical benefit has been observed even in patients
with normal activity of the two respiratory chain complexes (III and IV) that are directly
involved in the electron transfers specifically required for pyrimidine biosynthesis.

Furthermore, it is an unexpected and an important aspect of the invention that higher
doses of pyrimidine nucleotide precursors of the invention are typically required for optimal
treatment effects in patients with mitochondrial cytopathies than are required for adequate
treatment of patients with a virtually complete block in de novo pyrimidine synthesis, e.g.
homozygotes for Type I orotic aciduria. Optimum doses of a compound of the invention, e.g.
triacetyluridine (which is efficiently absorbed after oral administration), for treatment of
congenital mitochondrial disease in children are in the range of 1 to 6 grams per m 2 of body
surface area (50 to 300 mg/kg, advantageously 100 to 300 mg/kg), whereas total daily de novo
synthesis of pyrimidines is approximately one gram per day in adults (about 0.5 gram/m 2 ).

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The broad applicability of the methods of the invention are unexpected and set the
compounds and compositions of the invention apart from other therapies of mitochondrial
disease that have been attempted e.g. Coenzyme Q, B vitamins, carnitine, and lipoic acid,
which generally address very specific reactions and cofactors involved in mitochondrial
function and which are therefore useful only in isolated cases. However, such metabolic
interventions with antioxidants and cofactors of respiratory chain complexes are compatible
with concurrent treatment with compounds and compositions of the invention, and in fact are
used to their best advantage in combination with compounds and compositions of the invention.

Treatment of neuromusc ular degenerative disorders

Friedreich 's Ataxia

A gene defect underlying Friedreich's Ataxia (FA), the most common hereditary ataxia,
was recently identified and is designated "frataxin". In FA, after a period of normal -
development, deficits in coordination develop which progress to paralysis and death, typically
between the ages of 30 and 40. The tissues affected most severely are the spinal cord, peripheral
nerves, myocardium, and pancreas. Patients typically lose motor control and are confined to
wheel chairs, and are commonly afflicted with heart failure and diabetes.

The genetic basis for FA involves GAA trinucleotide repeats in an intron region of the
gene encoding frataxin. The presence of these repeats results in reduced transcription and
expression of the gene. Frataxin is involved in regulation of mitochondrial iron content. When
cellular frataxin content is subnormal, excess iron accumulates in mitochondria, promoting
oxidative damage and consequent mitochondrial degeneration and dysfunction.

When intermediate numbers of GAA repeats are present in the frataxin gene intron, the
severe clinical phenotype of ataxia may not develop. However, these intermediate-length
trinucleotide extensions are found in 25 to 30% of patients with non-insulin dependent diabetes
mellitus, compared to about 5% of the nondiabetic population.

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Compounds and compositions of the invention are useful for treating patients with
disorders related to deficiencies or defects in frataxin, including Friedreich's Ataxia,
myocardial dysfunction, diabetes mellitus and complications of diabetes like peripheral
neuropathy. Conversely, diagnostic tests for presumed frataxin deficiencies involving PCR
tests for GAA intron repeats are useful for identifying patients who will benefit from treatment
with compounds and compositions of the invention.

Muscular Dystrophy

Muscular dystrophy refers to a family of diseases involving deterioration of
neuromuscular structure and function, often resulting in atrophy of skeletal muscle and
myocardial dysfunction. In the case of Duchenne muscular dystrophy, mutations or deficits in a
specific protein, dystrophin, are implicated in its etiology. Mice with their dystrophin genes
inactivated display some characteristics of muscular dystrophy, and have an approximately 50%
deficit in mitochondrial respiratory chain activity. A final common pathway for neuromuscular
degeneration in most cases is calcium-mediated impairment of mitochondrial function.
Compounds and compositions of the invention are useful for reducing the rate of decline in
muscular functional capacities and for improving muscular functional status in patients with
muscular dystrophy.

Multiple sclerosis

Multiple sclerosis (MS) is a neuromuscular disease characterized by focal inflammatory
and autoimmune degeneration of cerebral white matter. Periodic exacerbations or attacks are
significantly correlated with upper respiratory tract and other infections, both bacterial and
viral, indicating that mitochondrial dysfunction plays a role in MS. Depression of neuronal
mitochondrial respiratory chain activity caused by Nitric Oxide (produced by astrocytes and
other cells involved in inflammation) is implicated as a molecular mechanism contributing to

MS.

Compounds and compositions of the invention are useful for treatment of patients with
ltiple sclerosis, both prophylactically and during episodes of disease exacerbation.

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Treatment of disorders of neuronal instability
Treatment of seizure disorders

Epilepsy is often present in patients with mitochondrial cytopathies, involving a range of
seizure severity and frequency, e.g. absence, tonic, atonic, myoclonic, and status epilepticus,
occurring in isolated episodes or many times daily.

In patients with seizures secondary to mitochondrial dysfunction, compounds and
methods of the invention are useful for reducing frequency and severity of seizure activity.

Treatment and prevention of migraine

Metabolic studies on patients with recurrent migraine headaches indicate that deficits in
mitochondrial activity are commonly associated with this disorder, manifesting as impaired -
oxidative phosphorylation and excess lactate production. Such deficits are not necessarily due
to genetic defects in mitochondrial DNA. Migraineurs are hypersensitive to nitric oxide, an
endogenous inhibitor of Cytochrome c Oxidase. In addition, patients with mitochondrial
cytopathies, e.g. MELAS, often have recurrent migraines.

In patients with recurrent migraine headaches, compounds, compositions, and methods
of the invention are useful for prevention and treatment, especially in the case of headaches
refractory to ergot compounds or serotonin receptor antagonists.

As demonstrated in Example 1, compounds and compositions of the invention are useful
for treatment of migraines associate with mitochondrial dysfunction.

Treatment of developmental delay

Delays in neurological or neuropsychological development are often found in children
with mitochondrial diseases. Development and remodeling of neural connections requires
intensive biosynthetic activity, particularly involving synthesis of neuronal membranes and

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myelin, both of which require pyrimidine nucleotides as cofactors. Uridine nucleotides are
involved inactivation and transfer of sugars to glycolipids and glycoproteins. Cytidine
nucleotides are derived from uridine nucleotides, and are crucial for synthesis of major
membrane phospholipid constituents like phosphatidylcholine, which receives its choline
moiety from cytidine diphosphocholine. In the case of mitochondrial dysfunction (due to
either mitochondrial DNA defects or any of the acquired or conditional deficits like exicitoxic
or nitric oxide-mediated mitochondrial dysfunction described above) or other conditions
resulting in impaired pyrimidine synthesis, cell proliferation and axonal extension is impaired at
crucial stages in development of neuronal interconnections and circuits, resulting in delayed or
arrested development of neuropsychological functions likelanguage, motor, social, executive
function, and cognitive skills. In autism for example, magnetic resonance spectroscopy
measurements of cerebral phosphate compounds indicates that there is global undersynthesis of
membranes and membrane precursors indicated by reduced levels of uridine diphospho-sugars,
and cytidine nucleotide derivatives involved in membrane synthesis(Minshew et al., Biological
Psychiatry 33:762-773, 1993).

Disorders characterized by developmental delay include Rett's Syndrome, pervasive
developmental delay (or PDD-NOS: "pervasive developmental delay - not otherwise specified"
to distinguish it from specific subcategories like autism), autism, Asperger's Syndrome, and
Attention Deficit/Hyperactivity Disorder(ADHD), which is becoming recognized as a delay or
tag in development of neural circuitry underlying executive functions.

Compounds and compositions of the invention are useful for treating patients with
neurodevelopmental delays involving motor, language, executive function, and cognitive skills.
Current treatments for such conditions, e.g. ADHD, involve amphetamine-like stimulants that
enhance neurotransmission in some affected underdeveloped circuits, but such agents, which
may improve control of disruptive behaviors, do not improve cognitive function, as they do not
address underlying deficits in the structure and interconnectedness of the implicated neural
circuits.

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Compounds and compositions of the invention are also useful in the case of other delays
or arrests of neurological and neuropsychological development in the nervous system and
somatic development in non-neural tissues like muscle and endocrine glands.

Treatment of neurodegenerative disorders

The two most significant severe neurodegenerative diseases associated with aging,
Alzheimer's Disease (AD) and Parkinson's Disease (TO), both involve mitochondrial
dysfunction in their pathogenesis. Complex I deficiencies in particular are frequently found not
only in the nigrostriatal neurons that degenerate in Parkinson's disease, but also in peripheral
tissues and cells Uke muscle and platelets of Parkinson's Disease patients.

In Alzheimer's Disease, mitochondrial respiratory chain activity is often depressed,
especially Complex IV (Cytochrome c Oxidase). Moreover, mitochondrial respiratory
function altogether is depressed as a consequence of aging, further amplifying the deleterious
sequelae of additional molecular lesions affecting respiratory chain function.

Other factors in addition to primary mitochondrial dysfunction underlie
neurodegeneration in AD, PD, and related disorders. Excitotoxic stimulation and nitric oxide
are implicated in both diseases, factors which both exacerbate mitochondrial respiratory chain
deficits and whose deleterious actions are exaggerated on a background of respiratory chain
dysfunction.

Huntington's Disease also involves mitochondrial dysfunction in affected brain regions,
with cooperative interactions of excitotoxic stimulation and mitochondrial dysfunction
contributing to neuronal degeneration. In example 8, a compound of the invention,
triacetyluridine, prevents neuronal cell death in a murine model of Huntington's disease.

Compounds and compositions of the invention are useful for treating and attenuating
progression of age-related neurodegenerative disease including AD and PD.

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Amyotrophic lateral sclerosis

One of the major genetic defects in patients with Amyotrophic Lateral Sclerosis (ALS;
Lou Gehrig's Disease; progressive degeneration of motor neurons, skeletal muscle atrophy,
inevitably leading to paralysis and death) is mutation or deficiency in Copper-Zinc Superoxide
Dismutase (SOD1), an antioxidant enzyme. Mitochondria both produce and are primary targets
for reactive oxygen species. Inefficient transfer of electrons to oxygen in mitochondria is the
most significant physiological source of free radicals in mammalian systems. Deficiencies m
antioxidants or antioxidant enzymes can result in or exacerbate mitochondrial degeneration.
Mice transgenic for mutated SOD1 develop symptoms and pathology similar to those inhuman
ALS. The development of the disease in these animals has been shown to involve oxidative
destruction of mitochondriafollowed by functional decline of motor neurons and onset of -
clinical symptoms (Kong and Xu, J. Neurosci. 18:3241-3250, 1998). Skeletal muscle from ALS
patients has low mitochondrial Complex I activity (Wiedemann et al., J. Neurol. Sci 156:65-72,
1998).

Compounds, compositions, and methods of the invention are useful for treatment of
ALS, for reversing or slowing the progression of clinical symptoms.

Protection against ischemia and hypoxia

Oxygen deficiency results in both direct inhibition of mitochondrial respiratory chain
activity by depriving cells of a terminal electron acceptor for Cytochrome c reoxidation at
Complex W, and indirectly, especially in the nervous system, via secondary post-anoxic
excitotoxicity and nitric oxide formation.

In conditions like cerebral anoxia, angina or sickle cell anemia crises, tissues are
relatively hypoxic. In such cases, compounds of the invention provide protection of affected
tissues from deleterious effects of hypoxia, attenuate secondary delayed cell death, and
accelerate recovery from hypoxic tissue stress and injury.

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Compounds and compositions of the invention are useful for preventing delayed cell
death (apoptosis in regions like the hippocampus or cortex occurring about 2 to 5 days after an
episode of cerebral ischemia) after ischemic or hypoxic insult to the brain.

Renal tubular acidosis

Acidosis due to renal dysfunction is often observed inpatients with mitochondrial
disease, whether the underlying respiratory chain dysfunction is congenital or induced by -
ischemia or cytotoxic agents like cisplatin. Renal tubular acidosis often requires administration
of exogenous sodium bicarbonate to maintain blood and tissue pH.

In Example 3, administration of a compound of the invention caused an immediate
reversal of renal tubular acidosis in a patient with a severe Complex I deficiency. Compounds
and compositions of the invention are useful for treating renal tubular acidosis and other forms
of renal dysfunction caused by mitochondrial respiratory chain deficits.

Age-related neurodegeneration and cognitive decline

During normal aging, there is a progressive decline in mitochondrial respiratory chain
function. Beginning about age 40, there is an exponential rise in accumulation of mitochondrial
DNA defects in humans, and a concurrent decline in nuclear-regulated elements of
mitochondrial respiratory activity.

de Grey (Bioessays, 19:161-167, 1998) discussed mechanisms underlying the
observation that many mitochondrial DNA lesions have a selection advantage during
mitochondrial turnover, especially in postmitotic cells. The proposed mechanism is that
mitochondria with a defective respiratory chain produce less oxidative damage to themselves
than do mitochondria with intact functional respiratory chains (mitochondrial respiration is the
primary source of free radicals in the body). Therefore, normally-functioning mitochondria
accumulate oxidative damage to membrane lipids more rapidly than do defective mitochondria,
and are therefore "tagged" for degradation by lysosomes. Since mitochondria within cells have
a half life of about 10 days, a selection advantage can result in rapid replacement of functional -

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mitochondria with those with diminished respiratory activity, especially in slowly dividing
cells. The net result is that once a mutation in a gene for a mitochondrial protein that reduces
oxidative damage to mitochondria occurs, such defective mitochondria will rapidly populate the
cell, diminishing or eliminating its respiratory capabilities. The accumulation of such cells
results in aging or degenerative disease at the organismal level. This is consistent with the
progressive mosaic appearance of cells with defective electron transport activity in muscle, with
cells almost devoid of Cytochrome c Oxidase (COX) activity interspersed randomly amidst
cells with normal activity, and a higher incidence of COX-negative cells in biopsies from older
subjects. The organism, during aging, or in a variety of mitochondrial diseases, is thus faced
with a situation in which irreplaceable postmitotic cells (e.g. neurons, skeletal and cardiac
muscle) must be preserved and their function maintained to a significant degree, in the face of
an inexorable progressive decline in mitochondrial respiratory chain function. Neurons with
dysfunctional mitochondria become progressively more sensitive to insults like excitotoxic
injury. Mitochondrial failure contributes to most degenerative diseases (especially
neurodegeneration) that accompany aging.

Congenital mitochondrial diseases often involve early-onset neurodegeneration similar
in fundamental mechanism to disorders that occur during aging of people born with normal
mitochondria. The demonstration disclosed in the Examples that compounds and compositions
of the invention are useful in treatment of congenital or early-onset mitochondrial disease
provides direct support for the utility of compounds and compositions of the invention for
treatment of age-related tissue degeneration.

Compounds and compositions of the invention are useful for treating or attenuating
cognitive decline and other degenerative consequences of aging.

Mitochondria and cancer chemotherapy

Mitochondrial DNA is typically more vulnerable to damage than is nuclear DNA for
several reasons:

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1 . Mitochondrial DNA has a less sophisticated repair system than does nuclear DNA.

2. Virtually all of the mitochondrial DNA strands encode important proteins, so that any defect
will potentially affect mitochondrial function. Nuclear DNA contains long regions that do
not encode proteins, wherein mutations or damage are essentially inconsequential.

3 . Defective mitochondria often have a selection advantage over normal, active ones during
proliferation and turnover.

4. Mitochondrial DNA is not protected by histones

Empirically, mitochondrial DNA damage is more extensive and persists longer than nuclear
DNA damage in cells subjected to oxidative stress or cancer chemotherapy agents like cisplatin
due to both greater vulnerability and less efficient repair of mitochondrial DNA. Although
mitochondrial DNA may be more sensitive to damage than nuclear DNA, it is relatively
resistant,in some situations, to mutagenesis by chemical carcinogens. This is because
mitochondria respond to some types of mitochondrial DNA damage by destroying their
defective genomes rather than attempting to repair them. This results in global mitochondrial
dysfunction for a period after cytotoxic chemotherapy. Clinical use of chemotherapy agents
like cisplatin, mitomycin, and Cytoxan is often accompanied by debilitating "chemotherapy
fatigue", prolonged periods of weakness and exercise intolerance which may persist even after
recovery from hematologic and gastrointestinal toxicities of such agents.

Compounds, compositions, and methods of the invention are useful for treatment and
prevention of side effects of cancer chemotherapy related to mitochondrial dysfunction. This
use of pyrimidine nucleotide precursors for attenuation of cancer chemotherapy side effects is
mechanistically and biochemically distinct from toxicity reduction of cytotoxic anticancer -
pyrimidine analogs by pyrimidine nucleotide precursors, which is mediated though
biochemical competition at the level of nucleotide antimetabolites.

Example 5 illustrates the protective effect of oral triacetyluridine in protecting against
taxol-induced neuropathy.

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Furthermore, hepatic mitochondrial redox state is one contributor to appetite regulation.
Cancer patients often display "early satiety", contributing to anorexia, weight loss, and
cachexia. Energy metabolism is often seriously disrupted in cancer patients, with energy-
wasting futile cycles of hyperactive tumor glycolysis producing circulating lactate, which is
converted by the liver back to glucose. Chemotherapy-induced mitochondrial injury further
contributes to metabolic disruption.

As indicated in Example 2, treatment with a compound of the invention resulted in
improved appetite in a patient with mitochondrial disease.

Mitochondria and ovarian function

A crucial function of the ovary is to maintain integrity of the mitochondrial genome in
oocytes, since mitochondria passed onto a fetus are all derived from those present in oocytes at
the time of conception. Deletions in mitochondrial DNA become detectable around the age of
menopause, and are also associated with abnormal menstrual cycles. Since cells cannot
directly detect and respond to defects in mitochondrial DNA, but can only detect secondary
effects that affect the cytoplasm, like impaired respiration, redox status, or deficits in
pyrimidine synthesis, such products of mitochondrial function participate as a signal for oocyte
selection and follicular atresia, ultimately triggering menopause when maintenance of
mitochondrial genomic fidelity and functional activity can no longer be guaranteed. This is
analogous to apoptosis in cells with DNA damage, which undergo an active process of cellular
suicide when genomic fidelity can no longer be achieved by repair processes. Women with
mitochondrial cytopathies affecting the gonads often undergo premature menopause or display
primary cycling abnormalities. Cytotoxic cancer chemotherapy often induces premature
menopause, with a consequent increased risk of osteoporosis. Chemotherapy-induced
amenorrhea is generally due to primary ovarian failure. The incidence of chemotherapy-
induced amenorrhea increases as a function of age in premenopausal women receiving
chemotherapy, pointing toward mitochondrial involvement. Inhibitors of mitochondrial
respiration or protein synthesis inhibit hormone-induced ovulation, and furthermore inhibit
production of ovarian steroid hormones in response to pituitary gonadotropins. Women with

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Downs syndrome typically undergo menopause prematurely, and also are subject to early onset
of Alzheimer-like dementia. Low activity of cytochrome oxidase is consistently found in
tissues of Downs patients and in late-onset Alzheimer's Disease.

Appropriate support of mitochondrial function or compensation for mitochondrial
dysfunction therefore is useful for protecting against age-related or chemotherapy-induced
menopause or irregularities of menstrual cycling or ovulation. Compounds and compositions of
the invention, including also antioxidants and mitochondrial cofactors, are useful for treating
and preventing amenorrhea, irregular ovulation, menopause, or secondary consequences of
menopause.

In Example 1, treatment with acompound of the invention resulted in shortening of the
menstrual cycle. Since the patient was in a persistent luteal phase, her response indicates that
the administered pyrimidine nucleotide precursor reversed hyporesponsiveness to pituitary
gonadotropins, which were presumably elevated to compensate for the ovarian
hyporesponsiveness of mitochondrial origin.

Diagnosis of mitochondrial disease

The striking response of patients with mitochondrial disease to administration of
compounds of the invention indicates that a clinical response to a pyrimidine nucleotide
precursor administered according to the methods of the subject invention has diagnostic utility
to detect possible mitochondrial disease. Molecular diagnosis of molecular lesions underlying
mitochondrial dysfunction is difficult and costly, especially when the defect is not one of the
more common mutations or deletions of mitochondrial DNA. Definitive diagnosis of
mitochondrial disease often requires muscle biopsies, but even this invasive measure only
works if mitochondrial defects are present in muscle. Since the compounds and compositions
of the invention are safe when administered in accord with the methods of the subject invention,
therapeutic challenge with a pyrimidine nucleotide precursor is an important diagnostic probe
for suspected mitochondrial disease, especially when used in conjunction with tests for various
other aspects of mitochondrial dysfunction.

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For diagnosis of congenital mitochondrial cytopathy, daily doses of 50 to 300 mg/kg of
a pyrimidine nucleotide precursor of the invention are administered to a patient for a period of
one to twelve weeks and clinical signs and symptoms are monitored for changes. Improvements
observed in the patients described in the Examples and additional patients include but are not
limited to reduction of frequency and severity of seizures, migraines, and stroke-like episodes,
improvement of weight gain in children with "failure to thrive", amelioration of renal tubular
acidosis with concurrent reduction in the need for supplementary bicarbonate, improvement of
muscular strength, improvement of speech acquisition, improvement of ataxia, improvement of
hypotonia, reduction of the frequency and severity of sinus and ear infections, improvement of
memory, and amelioration of symptoms of autonomic and peripheral neuropathy. In one
embodiment of the invention, other tests of mitochondrial function are also used to provide
evidence for diagnosis of mitochondrial disease. Diagnosis typically requires cumulative
consideration of a number of corroborative tests with differing degrees of reliability, as
described in Walker et al, (Eur Neurol., 36:260-7, 1996). Therapeutic responsiveness to a
pyrimidine nucleotide precursor of the invention is primarily useful as an additional minor
criterion in this diagnostic scheme, since it is possible that therapeutic benefits may occur after
aclministration of pyrimidine nucleotide precursors that are not mediated solely by
compensation for respiratory chain deficits. Since the nature and severity of symptoms of
mitochondrial diseases are heterogeneous and variable between patients, efficacy of exogenous
pyrimidine nucleotide precursors is typically assessed by selecting dominant symptoms in a
patient and monitoring their severity with as quantitative a scale as is feasible during a course of
therapy. If a possible placebo effect is suspected, blinded switching of the patient from drug to
an appropriate placebo is optionally used in an individual patient. Assessment of clinical
benefit can require considerable skill and experience, but such skill is in the province of
practitioners of the art of treating patients with multisystem metabolic diseases, and as such
does not constitute undue experimentation, in view of the severity of this class of diseases. The
examples cited below of clinical treatment of patients with mitochondrial diseases with
triacetyluridine, a compound of the invention, exemplify the feasibility of determining clinical
benefit in individual patients.

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E. Administration and Formulation of Compounds and Compositions of the Invention

In the case of all of the specific therapeutic targets for pyrimidine nucleotide precursor
therapy of mitochondrial disease, compounds of the invention are typically administered one to
three times per day. Acyl derivatives of uridine and cytidine are administered orally in doses of
10 to 500 mg/kg of body weight per day, with variations within this range depending on the
amount required for optimal clinical benefit. Generally, optimum doses are between 50 and 300
mg/kg/day (advantageously 100 to 300 mg/kg/day), divided into two or three separate doses
taken 6 to 12 hours apart. Uridine and cytidine are less efficiently absorbed than are acyl
derivatives of these two nucleosides, so that higher doses are required for therapeutic benefit
comparable to that achieved with acyl derivatives. Osmotic diarrhea limits the amount of
uridine or cytidine (or other derivatives like cytidine diphosphocholine) that can be
administered to a patient, so that in most cases acyl derivatives of cytidine and uridine are more
effective than the parent compounds, with fewer side effects. Doses of cytidine and uridine
used to accomplish the purposes of the invention range from 50 to 1000 mg/kg/day,
advantageously 100 to 1000 mg/kg/day, depending on the balance beween therapeutic efficacy
and tolerability. Orotate or alcohol esters of orotate are administered orally in doses ranging
from 20 to 200 mg/kg/day, again depending on the amount needed to achieve an optimal
therapeutic effect in a particular disease state involving mitochondrial respiratory chain
dysfunction. The dose of pyrimidine nucleotide precursor of the invention required for a
particular disease or patient will also depend in part on the severity of the disease.

In any individual patient with a disease characterized or caused by mitochondrial
dysfunction, an effective dose of a pyrimidine nucleotide precursor of the invention is typically
determined empirically. In congenital mitochondrial diseases, also known as mitochondrial
cytopathies or mitochondrial encephalomyopathies, the clinical presentation of signs and
symptoms is generally heterogeneous and variable between patients. Clinical benefit following
administration of a compound of the invention is determined by monitoring a set of symptoms
and assessing their severity over time, e.g. at monthly intervals. Three to five dominant
symptoms are selected for this purpose, and the degree of amelioration judged to constitute
clinical benefit is often a matter of clinical judgment. In treatment of patients with complex
metabolic disorders, such assessment does not constitute undue burden of experimentation,

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especially given the severity (often life threatening) of mitochondrial cytopathies and the costly
nature of their care. Compensation for mitochondrial or other metabolic defects as early as
possible in the patients life can make a very large difference versus intervention after
development of the brain and body achieves stasis after puberty. It is therefore worthwhile for
considerable effort to be expended on diagnosis and treatment of complex metabolic diseases,
especially in developing children. The examples cited below of clinical improvement following
administration of a compound of the invention to patients with mitochondrial diseases
demonstrate the feasibility and value of such treatment and assessment.

In the case of most diseases with less heterogeneity in clinical presentation than
mitochondrial disease, there exist in the art appropriate validated assessment scales for
determining efficacy of drug treatments. Prior to conducting clinical studies to determine the
doses of pyrimidine nucleotide precursors of the invention for treatment of the disease
conditions disclosed in the instant specification, appropriate doses for individual patients are
determined by evaluating clinical response (including brain MRI images and other indices, e.g.
biochemical measurements, that may not necessarily be clinically apparent simply by
observation of the patient's symptoms) according to quantitative disease assessment scales. In
all cases, the dominant symptoms of a particular disease state are monitored over time to
determine whether an improvement of signs and symptoms or attenuation of clinical decline
occurs, as is common in the art of medicine. Prior to dose determination in blinded clinical
studies, the response of a given patient to a pyrimidine nucleotide precursor of the invention is
be differentiated from a possible placebo effect simply by blinded switchover from drug to
placebo for a period of several weeks.

In the case of patients unable to receive oral medications, compounds of the invention,
especially uridine, cytidine, and orotate esters can be administered, as required, by prolonged
intravenous infusion, delivering daily doses of 10 to 500 mg/kg/day.

The pharmacologically active compounds optionally are combined with suitable
pharmaceutically acceptable carriers comprising excipients and auxiliaries which facilitate
processing of the active compounds. These are administered as tablets, suspensions, solutions,
dragees, capsules, or suppositories. The compositions are administered for example orally,

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rectally, vaginally, or released through the buccal pouch of the mouth, and may be applied in
solution form by injection, orally or by topical administration. The compositions may contain
from aboutO.l to 99 percent, preferably from about 50 to 90 percent of the active compound(s),
together with the excipient(s).

For parenteral administration by injection or intravenous infusion, the active compounds
are suspended or dissolved in aqueous medium such as sterile water or saline solution. -
Injectable solutions or suspensions optionally contain a surfactant agent such as
polyoxyethylenesorbitan esters, sorbitan esters, polyoxyethylene ethers, or solubilizing agents
like propylene glycol or ethanol. The solution typically containsO.Ol to 5% of the active
compounds.

Suitable exctpients include fillers such as sugars, for example lactose, sucrose, mannitol
or sorbitol, cellulose preparations and/or calcium phosphates, for example tricalcium phosphate
or calcium hydrogen phosphate, as well as binders such as starch paste, using, for example,
maize starch, wheat starch, rice starch or potato starch, gelatin, tragacanth, methyl cellulose,
hydroxypropylmethyl cellulose, sodium carboxymethyl cellulose and/or polyvinyl pyrrolidone.

Auxiliaries include flow-regulating agents and lubricants, for example, silica, talc,
stearic acid or salts thereof, such as magnesium stearate or calcium stearate and/or
polyethylene glycol. Dragee cores are provided with suitable coatings which, if desired, are
resistant to gastric juices. For this purpose, concentrated sugar solutions are used, which
optionally contain gum arabic, talc, polyvinyl pyrrolidone, polyethylene glycol and/or titanium
dioxide, lacquer solutions and suitable organic solvents or solvent mixtures. In order to produce
coatings resistant to gastric juices, solutions of suitable cellulose preparations such as acetyl
cellulose phthalate or hydroxypropylmethyl cellulose phthalate are used. Dyestuffs or pigments
are optionally added to the tablets or dragee coatings, for example, for identification or in order
to characterize different compound doses.

The pharmaceutical preparations of the present invention are manufactured in a manner
which is itself known, for example, by means of conventional mixing, granulating, dragee-
making, dissolving, or lyophilizing processes. Thus, pharmaceutical preparations for oral use

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are obtained by combining the active compound(s) with solid excipients, option-ally grinding
the resulting mixture and processing the mixture of granules, after adding suitable auxiliaries, if
desired or necessary, to obtain tablets or dragee cores.

Other pharmaceutical preparations which are useful for oral delivery include push-fit
capsules made of gelatin, as well as soft-sealed capsules made of gelatin and a plasticizer such
as glycerol ot sorbitol. The push-fit capsules contain the active compound(s) in the form of
granules which optionally are mixed with fillers such as lactose, binders such as starches and/or
lubricants such as talc or magnesium stearate, and, optionally stabilizers. In soft capsules, the
active compounds are preferably dissolved or suspended in suitable liquids such as tatty oils,
liquid paraffin, or polyethylene glycols. In addition, stabilizers optionally are added.

Pharmaceutical preparations which are used rectally include, for example, suppositories
which consist of a combination of active compounds with a suppository base. Suitable
suppository bases are, for example, natural or synthetic triglycerides, paraffin hydrocarbons,
polyethylene glycols or higher alkanols. In addition, gelatin rectal capsules which consist of a -
combination of the active compounds with a base are useful. Base materials include, for
example, liquid triglycerides, polyethylene glycols, or paraffin hydrocarbons. In another -
embodiment of the invention, an enema formulation is used, which optionally contains
viscosity-increasing excipients like methylcellulose, hydroxypropylmethylcellulose,
carboxymethycellulose, carbopol, glycerine polyacrylates, or other hydrogels.

Suitable formulations for parenteral administration include aqueous solutions of the
active compounds in water soluble form, for example, water soluble salts.

In addition, suspensions of the active compounds as appropriate in oily injection
suspensions are administered. Suitable lipophilic solvents or vehicles include fatty oils, for -
example, sesame oil, or synthetic fatty acid esters, for example, ethyl oleate or triglycerides.
Aqueous injection suspensions optionally include sub-stances which increase the viscosity of
thesuspension which include, for example, sodium carboxymethyl cellulose, sorbitol and/or
dextran. The suspension optionally contains stabilizers.

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F. Synthesis of the Compounds of the Invention

Acyl derivatives of cytidine and uridine are synthesized typically by acylation methods
involving reaction of acid chlorides or acid anhydrides with cytidine or uridine.

The synthesis of 2',3 , ,5'-tri-0-pyruvyluridine is shown in Example 6.

* * *

The following examples are illustrative, but not limiting of the methods and compositions of
the present invention. Other suitable modifications and adaptations of a variety of conditions
and parameters normally encountered in clinical therapy which are obvious to those skilled in
the art are within the spirit and scope of this invention.

Examples

Kxamnle 1 : Treatment of a multisystem m i tnr.hnndrial disorder with triacetyluridin , e

A 29 year old woman with a partial Complex I deficiency, and whose son was
diagnosed with mitochondrial disease leading to stroke-like episodes, ataxia, and
encephalopathy, presented with a multisystem mitochondrial disorder. Signs and symptoms
included hemiplegic/aphasic migraines, grand-mal seizures, neurogenic bowel and bladder
dysfunction, requiring catheterization approximately four times per day, dysphagia, autonomic
and peripheral polyneuropathy producing painful paresthesias, tachycardia/bradycardia
syndrome, and poor functional capacity with inability to climb a flight of stairs without stopping
to rest, and declining cognitive performance with episodes of clouded sensorium and poor
memory lasting hours to days.

After beginning treatment with 0.05 mg/kg/day of oral triacetyluridine, and for a
duration of at least 6 months, this patient has not had seizures or migraines; her paresthesias
related to peripheral neuropathy have resolved. She is able to void spontaneously on most days,
requiring catheterization only once or twice per week. After 6 weeks of treatment with

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triacetyluridine, this patient was able to walk a full mile, which she has been unable to do for
the past two years because of inadequate functional capacity. Her episodes of bradycardia
during sleep and tachycardia during exertion have reduced infrequency; prior to treatment,
tachycardia with a heart rate greater than 140 bpm occurred upon simple rise to stand, and after
6 weeks of triacetyluridine, tachycardia occurred only on hills and stairs. Her sensorium has
cleared and memory deficits have improved markedly.

During treatment, this patients' menstrual cycles shortened from 4 weeks to two weeks,
and she displayed a persistent luteal phase as evaluated by estradiol, progesterone, FSH and LH
measurements. After several months, her cycle normalized to 4 weeks.

This patient demonstrates important features of the subject invention, in that 1) the
compound of the invention caused improvements in virtually all features of a complex
multisystem disease related to mitochondrial dysfunction in a variety of tissues, and that 2)
compounds of the invention are unexpectedly useful for treating disease conditions related to a
partial Complex I deficiency, which affects a portion of the mitochondrial respiratory chain that
is outside of the sequence of electron transfers directly involved in de novo pyrimidine
biosynthesis.

The transient shortening of this patient's menstrual cycle is interpreted as an
improvement of ovarian function caused bytriacetyl uridine in the face of excessive hormonal
stimulation by which the neuroendocrine system was attempting to compensate for ovarian
dysfunction. Feedback between the ovaries and the hypothalamus led to gradual normalization
of cycle time.

Example 2: Treatment of refracto ry epilepsy

An 1 1 year old boy had refractory epilepsy since age 4.5, apparently due to a multiple
mitochondrial DNA deletion syndrome. In December 1997, his condition deteriorated,
including two admissions to an intensive care unit for crescendo epilepsy. Even with aggressive
regimens of standard anticonvulsive therapy.this patient was having 8 to 10 grand-mal seizures

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per night, leaving him unable to attend school regularly or participate in sports activities. He
also developed upper lip automaticity.

In the first three days after beginning treatment with oral triacetyluridine (initially at a
dose of 0.05 g/kg/day, and incrementally increased to 0.1 and then 0.24 g/kg/day ovct the
course of several weeks), there were no seizures, and involuntary lip movements ceased. There
has subsequently been some recurrence of seizures especially during episodes of infection,
though at a much lower frequency than prior to treatment with triacetyluridine. This patient has
been able to return to school and resume active participation in sports. His appetite, cognitive
function, and fine motor coordination have improved during therapy, resulting in improved
academic performance and in outstanding performance in sports activities like baseball.

Example 3: Treatment o f renal tubular acidosis

A 2 year-old girl, with Leigh's Syndrome (subacute necrotizing encephalopathy)
associated with severe Complex I deficiency, displayed renal tubular acidosis requiring
intravenous administration of 25 mEq per day of sodium bicarbonate. Within several hours
after beginning intragastric treatment with triacetyluridine at 0. 1 g/mg/day, her renal tubular
acidosis resolved and supplementary bicarbonate was no longer required to normalize blood pH.
Triacetyluridine also resulted in rapid normalization of elevated circulating amino acid
concentrations, and maintained lactic acid at low levels after withdrawal of dichloroacetate
treatment, which was previously required to prevent lactic acidosis.

Example 4; Treatment of developmental delay

A 4.5 year-old girl with epilepsy, ataxia, language delay, and fat intolerance, and
dicarboxylic aciduria was treated with triacetyluridine at a daily dose of 0. 1 to 0.3 g/kg/day.
Such treatment resulted in a 50% decline in seizure frequency, improvement of ataxia and
motor coordination, restoration of dietary fat tolerance, and rapidly accelerated development of
expressive language capabilities.

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Ryan-role 5: Prevention of taxol-induce d neuropathy

Peripheral neuropathy is a frequent, and often dose-lirniting, side effect of important
anticancer agents like cisplatin and taxol. In the case of taxol, sensory neuropathy occurs
several days after administration. Taxol's mechanism of action involves stabilization of
microtubules, which is useful for treating cancers, but is deleterious to peripheral neurons. -
Microtubule stabilization impairs axonal transport of cellular components. Mitochondria shuttle
between the cell body and terminals of neurons, so that the expression of mitochondrial -
respiratory chain components can be regulated by nuclear transcription factors. During
inhibition of mitochondrial shuttling, mitochondria distant from the nucleus undergo decline in
expression of respiratory chain subunits encoded by the mitochondrial genome, due to
inadequate exposure to mtDNA transcription factors, resulting in regional neuronal energy
failure and other consequences of mitochondrial dysfunction.

Two groups of 10 mice each were treated with taxol, 21.6mg/kg/day for 6 consecutive
days by intraperitoneal injection. An additional group of 10 mice received injections of vehicle
alone. One of the groups of taxol-treated mice received oral triacetyluridine, 4000 mg/kg b.i.d.
Nine days after the initiation of taxol treatments, nociceptive sensory deficits weretested by
determining tail-flick latency after exposure of the tip of the tail to focused thermal radiation
with an infrared heat lamp. In this system, delays in the tail-flick response to radiant heat
correlate with sensory nerve deficits.

Group: Tail flick latenc y

Control (no taxol) 10.8 ± 0.5 seconds

Taxo l 16.0 ± 3.1 seconds

Taxol + triacetyluridine H-9± 0.7 seconds

Taxol treatment impaired responses to painful stimuli as an index of toxic sensory
neuropathy. Oral triacetyluridine treatment significantly attenuated taxol-induced alterations in
tail-flick latency.

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Rxamnle 6: Sy ndesis of Uridine Pyruvate

A. The preparation of pyruvyl chloride was accomplished by the reaction of alpha, alpha-
dichloromethyl methyl ether and pyruvic acid using the procedure of Ottenheum and Man
(Synthesis, 1975,p. 163).

B. Uridine (3.0 g, 12 mmol) was dried by toluene azeotrope undervacuum (3x), and then
dissolved in DMF (20 mL) and pyridine (20mL). The resultant solution was cooled to -10
degrees C and 6.0mL of pyruvyl chloride (produced in step A above) was added dropwise. The
reaction mixture was stirred at room temperature under argon for 24 hours. Analysis by TLC
(5% MeOH/CH2C12) showed the consumption of uridine. The reaction mixture was evaporated
to dryness and partitioned between CH2C12 and aqueous sodium bicarbonate. The organic layer
was washed with water, aqueous HC1 (pH 3.0), and water, dried over sodium sulfate; -
concentrated; and purified using flash chromatography (silicagel, 5% MeOH/CH2C12) to yield
1.4 g of uridine pyruvate, or 2\3\5'-tri-0-pyruvyluridine.

F.y a ™n1e 7: Th^entic effect o f ™l triar.etvluridine. in the MPTP model of Parkinson's
disease CPD\ and mitochondrial dy sfunction

The neurotoxin l-methyM-phenyl-l^.S^-tetrahydropyridine (MPTP) is a complex I
(NADH dehydrogenase) mitochondrial respiratory chain inhibitor that is used to induce
dopaminergic cell loss (Varastet et al, Neuroscience, 63: 47-56,1994). This toxin is currently
widely used as an animal model for PD (Bezard et al., Exp Neurol, 148: 288-92, 1997).

Male C57/BL6 mice that were 6-9 months old weighing 30-40g from Taconic Farms
were used in the MPTP studies (n=7/group). MPTP (30 mg/kg i.p.) was given b.i.d. for 1.5
days. TAU was administered b.i.d. 4g/kg p.o. in 0.75% hydroxypropyl-methylcellulose vehicle
at 200 mg TAU /mL solution, 2 hours prior to toxin administration and until the day before
sacrifice.

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Eight days after stopping injection of MPTP, the mice were sacrificed by C0 2 and the
striata from both sides were dissected out on cold surface. The striatum was frozen on dry ice.
The dopaminergic neuronal survival was assessed by striatal dopamine (DA) content. The
dopamine content was assayed by a radioenzymatic method under GLP conditions, but DA can
also be measured using high pressure liquid chromatography with electrochemical detection as
previously described (Friedemann & Gerhardt, Neurobiol Aging, 13: 325-32, 1992). There was
a decreased mortality in the MPTP treated mice due to TAU treatment. The mortality in the
control + MPTP mice was 71.4% compared to 28.6% in the TAU + MPTP treatment group.
There was also a neuroprotective effect of PN401 treatment on the decrease in DA content due
to MPTP.

Effect of TAU on MPTP-induced decrease in striatal DA content

Treatment Striatal DA*

Control + Control 147 ± 13.0

TAU + Control 93. 8± 10.7

Control + MPTP 9.2 ± 2.2

TAU + MPTP 37.9 + 7.4

* Data are represented as ng DA/mg protein (mean ± SEM).

A second study using MPTP (25 mg/kg i.p. b.i.d. for 2 days) was performed. Male
C57/BL6 mice that were 6-9 months old weighing 30-40g from Taconic Farms were used in the
MPTP studies (n=6/group). MPTP (30 mg/kg i.p.) was given b.i.d. for 2 days. TAU was
administered b.i.d. 4g/kg bw p.o. in 0.75% hydroxypropyl-methylcellulose vehicle at 200 mg
TAU /mL solution 2 hours prior to toxin administration and until the day before sacrifice. TAU
or vehicle was given orally (dose of TAU = 4g/kg bw b.i.d.) starting the day before MPTP
administration and ending on day 8. Mice were sacrificed on day 9. This study also
demonstrated that TAU showed protective effects on dopaminergic neurons as indicated by an
attenuated decrease in striatal DA loss due to MPTP.

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Effect of TAU on MPTP-induced decrease in striatal DA content

Treatment

Striatal DA*

Control + Control

71.0 ±10.6

TAU + Control

52.0 ± 3.0

Control + MPTP

15.9 ±2.2

TAU + MPTP

26.7 ± 0.9

* Data are represented as ng DA/mg protein (mean ± SEM).

F.xamnle 8: Theraneutic effect of TAU m the 3-nitroprnpinnic acid ttNP^ model of
Huntington' s disease CHD)

HD is characterized by a progressive neuronal loss especially in the striatum. Patients
with HD have a decreased activity of succinate dehydrogenase (complex II)- ubiquinol
oxidoreductase (complex III) activity . Browne, Mitochondria & Free Radicals in
Neurodegenerative Diseases, 361-380 (1997). A widely used model of HD employs an
inhibitor of succinate dehydrogenase, 3-nitropropionic acid (3NP) . (Ferrante et a/.,
Mitochondria & Free Radicals in Neurodegenerative Diseases, 229-244, 1997). 3NP induces
damage to the striatum in particular. (Brouillet et al., J Neurochem, 60: 356-9, 1993).

Male 6-8 month old Swiss mice (National Cancer Institute; NCI, Frederick, MD) were
treated with 3NP (65 mg/kg i.p.) daily for 4 days to induce mortality, neuronal cell loss and
behavioral impairment with n=8/group. TAU was administered b.i.d. 4g/kg bw p.o. in 0.75%
hydroxypropyl-methylcellulose vehicle at 200 mg TAU /mL was given to the mice one day
before and every day until day 8. On day 9, the mice were perfuse fixed with 10% buffered
formalin and processed for silver staining to detect neuronal damage. There was decreased
mortality due to 3NP in the mice treated with TAU compared to the controls as shown below.

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There was no mortality in the 3NP + TAU group, but 3 of 8 mice died in the vehicle + 3NP
group.

Behavioral scoring of the 3NP treated mice was to determine whether there was any
motor impairment at anytime during the study. There were 88% of the control + 3NP treated
mice with behavioral impairment indicated by gross observation. A decreased incidence of
impairment of only 50% was found in the TAU + 3NP treated mice.

The silver staining was analyzed by a pathologist blinded to the identity of tissue
samples. There were no clear signs of neuronal damage detected in the TAU + 3NP treated
mice. However, in the control + 3NP treated mice, silver staining of synaptic terminals in the
striatal area (caudate/putamen area) and substantia nigra was pronounced. Silver impregnation
of axons and/or synaptic terminals in the thalamus, deep mesencephalon and/or reticular
formation (medulla) was also found in 80% of the control + 3NP treated mice. The substantia
nigra projects to the striatum and these areas are especially vulnerable to damage by 3NP. The
damage to the substantia nigra and striatum was prevented by TAU.

F.xamnle 9: Theraneutic effect of TAU in t h * l-nitropropionic acid (3NP) model of epilepsy

3-nitropropionic acid (3NP) is a mitochondrial toxin that acts by inhibiting Complex II
of the respiratory chain; it is used to induce brain lesions similar to those characteristic of
Huntington's disease. Seizures can also be induced by the use of 3NP as a model of epilepsy
and mitochondrial dysfunction. Urbanska et al, Eur J Pharmacol, 359: 55-8 (1998). Male CD-I
mice (National Cancer Institute.NCI, Frederick. MD) weighing between 26-40 g were used
throughout. Mice were divided into groups of 5 and animals for each group were randomly
chosen from different cages to avoid possible influence of age. The mice were maintained on a
1 2 hr light dark cycle with free access to water and food. All experiments were performed
during the light period between 9:00 and 16:00 hr. Mice (n-17-20) were given 160 mg/kg 3NP
and followed for seizures. 3NP was made up at I6mg or 18mg/ml in sterile water (pH: 7.4 ).
3NP was administered i.p. in a volume of O.lml/lOg body weight. TAU was administered
4g/kg p.o. in 0.75% hydroxypropyl-methylcellulose vehicle 2 hours prior to 3NP
administration. Seizures were assessed similar to the methods previously described (Roberts &

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Keith, J Pharmacol Exp Ther, 270: 505-1 1, 1994; Urbanska et al., Eur J Pharmacol, 359: 55-8,
1998).

Behavioral observations were performed within 120 min following application of 3-NP.
Three major categories of convulsive seizure response were been considered and recorded:

1 . Clonic movements: the movements of the forelimbs accompanied by facial twitching;

2. Explosive clonic movements: the movement of all four limbs involving ninning, jumping
and bouncing;

3 . Tonic response: including tonic flexion and tonic extension of the all four limbs.
Mortality rate was evaluated at 120 min after 3NP injection.

3NP induced primarily clonic seizures with some mice going on to develop a running
and jumping behavior that generally resulted in mortality. TAU decreased the percent
incidence of clonic seizure, running seizure and mortality due to 3NP. The primary endpoint
was the latency to clonic seizure. TAU increased the latency to clonic seizure from 25.0-40.8
minutes. Data are represented as mean ± SEM.

Endpoint

Control + 3NP TAU + 3NP

% Clonic seizures 90.0 70.6

% Running seizures 42.9 5.9

% Mortality 35 H-8

Latency to clonic seizure 23.8 ±0.7 40.8 ±4.9

F.xamnle 10: Therapeutic effect nf TAT? in th e ^uinnlinic acid (OA) model of excitotoxjtity

Quinolinic acid is an NMDA receptor agonist that has been used in models of
Huntington's disease and excitotoxic damage (Beal et al., J Neurosci, 11:1 649-59, 1 991 ; Bea
era/., J Neurosci, 11: 147-58, 1 991 ;Ferrantee/ al., Exp Neurol, 119:46-71, 1993). It can

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induce severe damage to the CNS when administered directly into the striatum. The damage
and/or mortality due to intrastriatal QA is likely due to a CNS etiology.

Male 6-8 month old Swiss mice (National Cancer Institute; NCI, Frederick, MD) were
treated with QA (50 or 100 nmoles given bilaterally in both striatum n=8/group. TAU was
administered b.i.d. 4g/kg bw p.o. in 0.75% hydroxypropyl-methylceUulose vehicle at 200 mg
TAU ImL was given to the mice one day before and every day until day 6. On day 7 the mice
were sacrificed. The QA was administered in a 2 ul volume as previously described (Tatter et
al., Neuroreport, 6: 1125-9, 1995).

There was a decreased mortality due to QA in the TAU treated mice. The percent of
mice surviving the 7 days treated with 50 nmoles QA was 64% in the control T QA and 73% in
the TAU + QA and for mice treated with 100 nmoles QA only 4% survived in the control + QA
group, whereas 19% survived in the TAU + QA group. TAU demonstrated a neuroprotective
effect on the excitotoxicity due to QA.

While the present invention has been described in terms of preferred embodiments, it is
understood that variations and modifications will occur to those skilled in the art. Therefore, it
is intended that the appended claims cover all such equivalent variations and modifications
which come within the scope of the invention as claimed.

SUBSTITUTE SHEET (RULE26)

WO 00/11952

PCT/US99/19725

CLAIMS

1 . A method for treating or preventing pathophysiological consequences of mitochondrial
respiratory chain dysfunction in a mammal comprising administering to said mammal in
need of such treatment or prevention an effective amount of a pyrimidine nucleotide.

2. A method as in claim 1 wherein said respiratory chain dysfunction is caused by a mutation,
deletion, or rearrangement of mitochondrial DNA.

3. A method as in claim 1 wherein said respiratory chain dysfunction is caused by defective
nuclear-encoded protein components of the mitochondrial respiratory chain.

4. A method as in claim 1 wherein said respiratory chain dysfunction is caused by aging.

5. A method as in claim 1 wherein said respiratory chain dysfunction is caused by
administration of cytotoxic cancer chemotherapy agents to said mammal.

6. A method as in claim 1 wherein said respiratory chain dysfunction is a deficit in
mitochondrial Complex I activity.

7. A method as in claim 1 wherein said respiratory chain dysfunction is a deficit in
mitochondrial Complex II activity.

8. A method as in claim 1 wherein said respiratory chain dysfunction is a deficit in
mitochondrial Complex III activity.

9. A method as in claim 1 wherein said respiratory chain dysfunction is a deficit in
mitochondrial Complex IV activity.

10. A method as in claim 1 wherein said respiratory chain dysfunction is a deficit in
mitochondrial Complex V activity.

SUBSTITUTE SHEET (RULE26)

WO 00/11952 PCTVUS99/19725

1 1 . A method as in claim 1 wherein said pyrimidine nucleotide precursor is selected from the
group consisting of uridine, cytidine, an acyl derivative of uridine, an acyl derivative of
cytidine, orotic acid, an alcohol ester of orotic acid, or a pharmaceutically acceptable salt
thereof.

12. A method as in claim 1 1 wherein said pyrimidine nucleotide precursor is an acyl derivative
of cytidine.

13. A method as in claim 1 1 wherein said pyrimidine nucleotide precursor is an acyl derivative
of uridine.

14. A method as in claim 1 1 wherein said acyl derivative of uridine is 2 l ,3 , ,5 , -tri-0-
acetyluridine.

15. A method as in claim 1 1 wherein said acyl derivative of uridine is 2 , ,3',5 , -tri-0-
pyruvyluridine.

16. A method as in claim 1 1 wherein the alcohol substituted of said alcohol ester of orotic acid
is ethanol.

1 7. A method as in claim 1 1 wherein said pyrimidine nucleotide precursor is cytidine
diphosphocholine.

18. a method as in claim 1 1 wherein said pyrimidine nucleotide precursor is administered
orally.

19. A method as in claim 1 1 wherein said pyrimidine nucleotide precursor is administered in a
dose of 10 to 1000 milligrams per kilogram of bodyweight per day.

20. A method as in claim 1 1 wherein said pyrimidine nucleotide precursor is administered in a
dose of 100 to 300 milligrams per kilogram of bodyweight per day.

SUBSTITUTE SHEET (RULE26)

WO 00/11952 52 PCI7US99/19725

2 1 . A method as in claim 1 wherein said pathophysiological consequence of mitochondrial
respiratory chain dysfunction is a congenital mitochondrial disease.

22. A method as in claim 21 wherein said congenital mitochondrial disease is selected from the
group consisting of MELAS, LHON, MERRF, MNGIE, NARP, PEO, Leigh's Disease, and
Kearns-Sayres Syndrome.

23. A method as in claim 1 wherein said pathophysiological consequence of mitochondrial
respiratory chain dysfunction is a neurodegenerative disease.

24. A method as in claim 23 wherein said neurodegenerative disorder is Alzheimer's Disease.

25. A method as in claim 23 wherein said neurodegenerative disorder is Parkinson's disease.

26. A method as in claim 23 wherein said neurodegenerative disorder is Huntington's Disease.

27. A method as in claim 23 wherein said neurodegenerative disorder is age-related decline in
cognitive function.

28. A method as in claim 1 wherein said pathophysiological consequence of mitochondrial
respiratory chain dysfunction is a neuromuscular degenerative disease.

29. A method as in claim 28 wherein said neuromuscular degenerative disease is selected from
the group consisting of muscular dystrophy, myotonic dystrophy, chronic fatigue syndrome,
and Friedreich's Ataxia.

30. A method as in claim 1 wherein said pathophysiological consequence of mitochondrial
respiratory chain dysfunction is developmental delay in cognitive, motor, language,
executive function, or social skills.

31. A method as in claim 1 wherein said pathophysiological consequence of mitochondrial
respiratory chain dysfunction is selected from the group consisting of epilepsy, peripheral -

SUBSTITUTE SHEET (RULE26)

WO 00/11952

PCT/US99/19725

neuropathy, optic neuropathy, autonomic neuropathy, neurogenic bowel dysfunction,
sensorineural deafness, neurogenic bladder dysfunction, migraine, and ataxia.

32. A method as in claim 1 wherein said pathophysiological consequence of mitochondrial
respiratory chain dysfunction is selected from the group consisting of renal tubular
acidosis, dilating cardiomyopathy, steatohepatitis, hepatic failure, and lactic acidemia.

33. A method for preventing death or functional decline of post-mitotic cells in a mammal due
to mitochondrial respiratory chain dysfunction comprising administration of an effective
amount of a pyrimidine nucleotide precursor.

34. A method as in claim 33 wherein said post-mitotic cells are neurons.

35. A method as in claim 33 wherein said post-mitotic cells are skeletal muscle cells.

36. A method as in claim 33 wherein said post-mitotic cells are cardiomyocytes.

37. A method for treating developmental delay in cognitive, motor, language, executive
function, or social skills in a mammal comprising administration of an effective amount of a
pyrimidine nucleotide.

~ 38. A method as in claim 37 wherein said developmental delay is pervasive developmental
delay or PDD-NOS.

39. A method as in claim 37 wherein said developmental delay is Attention
Deficit/Hyperactivity Disorder.

40. A method as in claim 37 wherein said developmental delay is Rett's Syndrome.

41 . A method as in claim 37 wherein said developmental delay is autism.

SUBSTITUTE SHEET (RULE26)

WO 00/1 1952 PCT/US99/19725

42. A method for reducing side effects of cytotoxic cancer chemotherapy agents by
administering a pyrimidine nucleotide precursor, where said cytotoxic chemotherapy agent
is not a pyrimidine nucleoside analog.

43. A method as in claim 42 wherein said side effects of cytotoxic cancer chemotherapy are
selected from the group consisting of peripheral neuropathy, chemotherapy-induced
menopause, chemotherapy-associated fatigue, and depressed appetite.

44. A method for diagnosing mitochondrial disease by administering a pyrimidine nucleotide
precursor and assessing clinical improvement in signs and symptoms in a mammal.

45. A compound selected from the group consisting of 2\3\5'-tri-0-pyruvyluridine, 2',3'-di-0-
pyruvyluridine, T^-di-O-pymvyluridine, S'^^di-O-pyruvyluridine^^O-pyruvyluridine, 3'-
O-pyruvyluridine, and S'-O-pyruvyluridine.

46. A pharmaceutical composition comprising:

(a) a pyrimidine nucleotide precursor or a pharmaceutical^ acceptable salt thereof, and

(b) pyruvic acid, a pharmaceutical^ acceptable salt thereof, or a pyruvic acid ester.

47. A method as in Claim I further comprising administering pyruvic acid, a pharmaceutical^
acceptable salt thereof, or a pyiuvic acid ester.

SUBSTITUTE SHEET (RULE26)

INTERNATIONAL SEARCH REPORT

International application No.
PCT/US99/19725

A. CLASSIFICATION OF SUBJECT MATTER
IPC(6) : A01N 43/04; A6UC 31/70
US CL : 514/49

According to International Patent Classification ((PC) or to both national classification and IPC

a FIELDS SEARCHED

Minimum documentation searched (classification system followed by classification symbols)
U.S. : 514/49

Documentation searched other than minimum documentation to the extent that such documents are included in the fields searched

Electronic data base consulted during the international search (name of data base and. where practicable, search terms used)
STN: medline, caplus, biosis, embase, biotechds

C DOCUMENTS CONSIDERED TO BE RELEVANT

Category*

Citation of document, with indication, where appropriate, of the relevant passages

Relevant to claim No.

X
A
X
Y
A

US 5,470,838 A (VAN DORS TEL) 28 November 1995, col. 13, lines
54-56; and col. 15, lines 6-12.

SECADES et al. CDP-Chollne: Pharmacollglcal and Clinical
Review. Methods and Findings In Experimental and Clinical
Pharmacology. October 1995, Vol. 17, Supplement 1, pages 1-54,
especially abstract, page 4, last full paragraph through page 5 col.
1; page 21, col.2 through page 22, and Figs, 11-13; page 38, col. 2
through page 39 eol. 1; pages 40-43, especially page 41, col.l, and
Table 18.

1, 11-14

15,16,44
1, 11, 17

1-11,18-42, 46

15,16,44

"x] Further documents are listed in the continuation of Box C. Q See patent family annex.

Special categories of cited documents: 'T* later document published after the intern atiooal filing date or priority

dale end not in conflict with the application but cited to understand
"A" document defining the general atate of the art which U not considered the principle or theory underlying the invention
to be of particular relevance

. *X* document of particular relevance, the claimed invention cannot be
"B" earlier document published on or after the international fiun$ data considered novel or cannot be considered to involve en inventive atep
'1/ document which may throw doubu on priority olaim(a) or which ia wneI » document is taken alone

cited to establish the publication date of another citation or other , •. • • j * .■ . w .

■ ifZan /M iDeeifiedl Y document of particular relevance; the oleimed invention cannot be
special reason <as tpe ) considered to involve an inventive step when the document it
"O* document referring to an oral discloiure, use, exhibition or other combined with one or more other such documents, such combination
m4anB being obvious to a person skilled in the art

'P* document published prior to the international filing data but later than *&• document member of the same patent family

Date of the actual completion of the international search
20 OCTOBER 1999

Date of mailing of the international search report

0 3 NOV 1999

Name and mailing address of the ISA/US
Commissioner of Patents and Trademark*
Box PCT

Washington, D.C. 20231
Facsimile No. (703) 305-3230

Authorised) office/^ , ^

RICHARD SCHNIZER /^<-
Telephone No. (703) 308-0196

Form PCT/ISA/210 (second sheetXJuly 1992)*

INTERNATIONAL SEARCH REPORT

International application No.
PCT/US99/19725

C (Continuation). DOCUMENTS CONSIDERED TO BE RELEVANT

Category*

Citation of document, with indication, where appropriate, of the relevant passages

Relevant to claim No,

Database Medline on STN AN 94049698, KEILBAUGH et ai.
Anti-human immunodeficiency virus type 1 therapy and peripheral
neuropathy: prevention of 2\ 3'-dideoxycytidine toxicity in PC 12
cells, a neuronal model, by uridine and pyruvate. Molecular
Pharmacology. October 1993. Vol. 44. No. 4. pages 702-706,
abstract only.

DYKENS, J.A. Isolated cerebral and cerebellar mitochondria
produce free radicals when exposed to elevated Ca2+ and Na+:
Implications for neurodegeneration. Journal of Neurochemistry.
1994, Vol. 63, pages 584-591, especially lines 24-28 of abstract;
and page 589, col. 1. first paragraph.

BODNAR et al. Respiratory-deficient human fibroblasts exhibiting
defective mitochondrial DNA replication. Biochem. J. 1995, Vol.
305, pages 817-822, especially abstract lines 6-10.

45
43

1-11,18-42, 46

2-10, 20, 21, 25-
42, 46

Form PCT/1SA/210 (continuation of second sheetXJuly 1992)*

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